IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:

DENTAL INSURANCE COMPANY #1

Dental Ins. Co.:

DENTAL INSURANCE COMPANY #2

Dental Ins. Co.:

Their phone #:

Their phone #:

Group #:

Group #:

Social Security or ID:

Social Security or ID:

DENTAL/MEDICAL HISTORY

Have you had any of the following medical conditions or problems?

PLEASE CHECK:

YesNo

Heart Murmur

YesNo

Hemophillia

YesNo

Cancer

YesNo

Heart problems of any kind

YesNo

Bledding problems

YesNo

Diabetes

YesNo

Convulsions / Epilepsy

YesNo

Hearing impairment

YesNo

HIV + / AIDS

YesNo

Hyperactive

YesNo

Any operations

YesNo

Rheumatic fever

YesNo

Any stays in hospital

YesNo

Glaucoma

YesNo

Hepatitis

YesNo

Latex Allergy

Are there any other medical conditions or problems?

YesNo

If yes, please list:

Are you currently under the care of a physician?

YesNo

Patient’s Physician:

City:

Phone #:

ARE YOU ALLERGIC TO ANY MEDICATIONS

YesNo

If yes, please list:

Are you taking any prescription Medications?

YesNo

If yes, please list:

DO YOU NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?

YesNo

Patient’s Dentist:

City:

Approximate date of last visit:

PLEASE CHECK:

Has there been any injuries to the face, mouth or teeth?

YesNo

Do you have any speech problems?

YesNo

Have you had tongue-thrust or speech therapy?

YesNo

Have you ever been informed of any missing or extra teeth?

YesNo

Have you ever been told you have TMJ (Temporomandibular Joint) problems?

YesNo

Does your jaw joint ever make noise (cracking or popping sounds) when chewing or yawning?

YesNo

Has your jaw ever locked open?

YesNo

When was the last dental care?

Interests ie. Sports, hobbies, etc.

WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH:

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in strictest of confidence, and it is my responsibility to inform this office of any changes in my health status.